Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures

Abstract

Purpose: To describe the presentation and management of complete upper airway obstruction with life threatening arterial oxygen desaturation that occurred during attempted awake fibreoptic intubation in two patients presenting with unstable C-spine injury. Clmic.~ F~tum: Complete upper airway obstruction occurred during awake fibreoptic intubation of two men (ASA II; 68 & 55 yr old) presenting with unstable C-spine fractures. In both cases, bag and mask ventilation with CPAP failed to relieve the progressive hypoxemia. A surgical airway was established urgently to oxygenate the two patients who were suffering progressive life-threatening oxygen desaturation. One patient had t~ns-cricothyroid jet ventilation performed through a 16G intravenous cannula prior to an urgent tracheostomy. In the other patient, an emergency tracheostomy was inserted. Interestingly, both patients had been sedated in the Neurosurgical Intensive Care Unit with morphine and benzodiazepines before their scheduled surgeries. The most likely etiology for the complete upper airway obstruction was laryngospasm due to inadequate topicalization of the airway and additional sedation given in the operating room. Neither patients suffered any new neurological deficits following these events. They went on to have uneventful surgeries. Condmion: This case report suggest that prior to awake fibreoptic intubation, oxygenation, adequate topicalization with testing to verify the lack of pharyngeal and laryngeal responses and careful assessment of sedation levels in the operating room are prudent for a safe endoscopic intubation. Obj~-tif: D&rire le tableau clinique et le traitement de robstruction compl&e des voies a~riennes sup&ieures, accompagn~e d'une dangereuse d&aturation du sang art~riel en oxyg~ne, survenue pendant qu'on tentait une fibroscopie vigile chez deux sujets souffrant d'une instabilit~ de la colonne cervicale. ~ealts dinique~ : Une obstruction complete des voies a&iennes sup&ieures s'est produite pendant une fibroscopie vigile chez deux hommes (ASA II ; 68 & 55 ans) qui pr~sentaient des fractures de la colonne cervicale. Dans les deux c.as, la ventilation manuelle au masque et au ballon et une ventilation spontan& avec pression expiratoire positive (PEP) n'a pu soulager I'hypox~mie progressive. Le r~tablissement chirurgical du conduit a&ien a ~t~ r~alis~ d'urgence pour oxyg~ner les deux patients qui souffraient d'une d~saturation progressive en oxyg~ne rnettant leur vie en danger. On a proc~d& chez run des patients, ~ une ventilation ~ jet transcricothyroidienne au moyen d'une canule intraveineuse 16G avant la trach~otomie d'urgence. Chez I'autre patient, une trach~otomie d'urgence a ~t~ pratiqu&. II est int&essant de rioter que les deux patients avaient re~u une s~dation ~ I'unit~ des soins intensifs neurochirurgicaux avec de la morphine et des benzodiaz~pines avant la chirurgie ~lective. I'~tiologie la plus probable de I'obstruction compl&e des voies a&i-ennes sup&ieures ~tait un laryngospasme caus~ par une puiv&isation inadequate du co...

The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study

“…It is also worth mentioning that 5% of the self-reported complications related to partial or complete compromise of airway patency simply with application of topical airway anesthesia. This has been previously described [28][29][30][31][32][33] but is an underappreciated phenomenon that underscores the need for an alternative plan even with the alleged safety margin provided by awake intubation.…”

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report

“…In one case report, Hiller describes a situation in which overflexion from halo fixation caused desaturation, tachypnea, and a challenging airway. 16 In another case report, McGuire et al describe two patients in halo traction who had complete upper airway obstruction after receiving topical treatment and sedation for awake bronchoscopic intubation. 17 It is possible that overflexion of the cervical spine went unrecognized in these cases and contributed to the development of airway obstruction.…”

Obstructing pathology of the upper airway in a post-NAP4 world: time to wake up to its optimal management

“…Conversely, optimal topical airway anesthesia may be difficult to obtain with some causes of OAP, and passage of an endoscope through a narrowed laryngeal aperture may be difficult or poorly tolerated by the awake patient. Furthermore, both local anesthesia itself [14][15][16] and concomitant sedation 17 have been reported to cause complete loss of airway patency during attempted awake intubation. The NAP4 data on awake oral or nasal intubation are difficult to interpret because the 23 recorded uses of flexible bronchoscopic intubation included its use in both anesthetized and awake patients.…”

“…De plus, des comptes rendus ont fait état d'une perte totale de la perméabilité des voies aériennes pendant une intubation éveillée causée tant par l'anesthésie locale en soi [14][15][16] que par la sédation concomitante. 17 Les données du NAP4 sur l'intubation orale ou nasale éveillée sont difficiles à interpréter. En effet, les 23 utilisations enregistrées d'une intubation par bronchoscope flexible regroupaient son utilisation chez les patients anesthésiés et chez les patients éveillés.…”