Difficult Airway Algorithm in a Patient with Stridor and Significant Airway Edema Upon Extubating

Abstract

INTRODUCTION: The difficult airway algorithm established by the American Society of Anesthesiologists (ASA) provides a set of guidelines for anesthesiologists to follow even before a patient is brought into the operating room. It begins with a physical exam evaluation of the airway in the preoperative period and the performance of a risk assessment with the available patient information. Although adequate preoperative evaluation can be presented and a difficult airway may not be expected, there are cases where an unanticipated difficult airway is encountered. Being prepared for such cases with the difficult airway algorithm in mind is crucial. The algorithm suggests beginning with bag mask ventilation and if failed, attempting placement and ventilation with a supraglottic airway. If this attempt fails, intubation can be attempted and lastly an emergency airway such as a cricothyrotomy or tracheotomy.1

CASE DESCRIPTION: A 60-year-old male ASA class 3 with a past medical history of a cerebellopontine angle (CPA) tumor, post-resection, presented for a palatoplasty for residual dysphonia and aspiration. After his initial CPA tumor resection, the patient had difficulty with airway management and a tracheotomy was performed. The tracheotomy had been removed prior to presentation for this procedure. On pre-operative assessment, the patient was a Mallampati class 2, and his airway exam was unremarkable. On induction, the patient received 200mg propofol and 100mg rocuronium for paralysis. The patient was an easy bag mask ventilation. A McGrath Mac 3 was used and with a Cormack-Lehane grade 2b view, a size 6.0 endotracheal tube (ETT) was placed. Anesthesia was maintained with sevoflurane. The patient remained hemodynamically stable throughout the case and no issues with extubation were expected; however, the patient was stridorous after extubation. Transnasal laryngoscopy revealed an edematous airway with significant supraglottic edema. The supraglottic obstruction was caused by manipulation during the surgery. The patient’s oxygen saturation began dropping. Bag mask ventilation with placement of an oral airway was unsuccessful. Laryngeal mask airway placement was attempted and unsuccessful. Video laryngoscopy was then attempted and showed edema and bleeding, leading to an unsuccessful reintubation. The decision was then made to perform an emergent tracheostomy to secure the airway.

DISCUSSION: Maintaining a secure airway to assure adequate oxygenation and ventilation of a patient is of utmost importance. Anticipating difficulties with airway management is critical before bringing a patient back in to the operating room. Keeping the difficult airway algorithm in mind, even when a patient’s pre-operative airway assessment does not have features indicative of a difficult bag mask ventilation or intubation, is crucial.

REFERENCES: 1. Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O’Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung; 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 2. Rosenberg MB, Phero JC. Airway Assessment for Office Sedation/Anesthesia. Anesth Prog. 2015 Summer;62(2):74-80; quiz 80-1. doi: 10.2344/0003-3006-62.2.74. PMID: 26061578; PMCID: PMC4462705.