Abstract:Central airway obstruction (CAO) is caused by many disease processes including malignant, benign and iatrogenic etiologies leading to significant morbidity and mortality. The most common malignant cause of CAO is direct extension from tumor. Bronchogenic, esophageal and thyroid cancers are amongst the most frequent malignant CAOs. Primary tracheal tumors are relatively less common and are usually due to squamous cell cancer and adenoid cystic carcinoma. Common benign causes of CAO are due to stenosis from prio… Show more
“…4 In severe cases of CAO, ECMO has been used when there are doubts in maintaining oxygenation with either an endotracheal tube or a rigid bronchoscopy. 5 Establishing an airway is challenging in patients with severe CAO as it may be distal and precludes the option of front of neck access. 5 The decision for pre-emptive standby of ECMO as a salvage therapy can be difficult.…”
Section: Discussionmentioning
confidence: 99%
“…5 Establishing an airway is challenging in patients with severe CAO as it may be distal and precludes the option of front of neck access. 5 The decision for pre-emptive standby of ECMO as a salvage therapy can be difficult. Hence, it is useful to assign the patient a severity grade of safe, uncertain, or unsafe based on the classification of anaesthetic risks for mediastinal mass syndrome.…”
Neurofibromatosis type 2 (NF2) is a rare autosomal dominant disorder. We report a case of a 52-year-old woman with underlying NF2 who was scheduled for excision of cervical neurofibromas. The patient had four nerve sheath tumours affecting different parts of the airway, namely, two cervical neurofibromas with spinal cord compression, a large retrosternal goitre extending into the anterior mediastinal compartment causing central airway obstruction, and a large left thoracic paravertebral tumour in the posterior mediastinal compartment. After risk stratification and multidisciplinary discussion, awake nasal fibreoptic intubation with a contingency plan of rigid bronchoscopy and jet ventilation was decided. The patient was intubated successfully with target-controlled infusion remifentanil as the sole sedative and airway topicalization with local anaesthetic. The patient was ventilated in a prone position intraoperatively with no desaturation. The tumours were successfully removed and the patient was discharged well. Awake nasal fibreoptic intubation is the choice of management in difficult airways affected by multicompartmental tumours in a centre that is devoid of extracorporeal membrane oxygenation service.
“…4 In severe cases of CAO, ECMO has been used when there are doubts in maintaining oxygenation with either an endotracheal tube or a rigid bronchoscopy. 5 Establishing an airway is challenging in patients with severe CAO as it may be distal and precludes the option of front of neck access. 5 The decision for pre-emptive standby of ECMO as a salvage therapy can be difficult.…”
Section: Discussionmentioning
confidence: 99%
“…5 Establishing an airway is challenging in patients with severe CAO as it may be distal and precludes the option of front of neck access. 5 The decision for pre-emptive standby of ECMO as a salvage therapy can be difficult. Hence, it is useful to assign the patient a severity grade of safe, uncertain, or unsafe based on the classification of anaesthetic risks for mediastinal mass syndrome.…”
Neurofibromatosis type 2 (NF2) is a rare autosomal dominant disorder. We report a case of a 52-year-old woman with underlying NF2 who was scheduled for excision of cervical neurofibromas. The patient had four nerve sheath tumours affecting different parts of the airway, namely, two cervical neurofibromas with spinal cord compression, a large retrosternal goitre extending into the anterior mediastinal compartment causing central airway obstruction, and a large left thoracic paravertebral tumour in the posterior mediastinal compartment. After risk stratification and multidisciplinary discussion, awake nasal fibreoptic intubation with a contingency plan of rigid bronchoscopy and jet ventilation was decided. The patient was intubated successfully with target-controlled infusion remifentanil as the sole sedative and airway topicalization with local anaesthetic. The patient was ventilated in a prone position intraoperatively with no desaturation. The tumours were successfully removed and the patient was discharged well. Awake nasal fibreoptic intubation is the choice of management in difficult airways affected by multicompartmental tumours in a centre that is devoid of extracorporeal membrane oxygenation service.
“…Others have come to a similar conclusion. 5,6 When veno-venous extracorporeal membrane oxygenation is available, and is delivered by adequately trained and experienced personnel, it should be considered as an option in the therapeutic management of difficult upper airway problems such as large, inhaled foreign bodies. Bronchoscopic removal of a foreign body is a common emergency procedure in otolaryngologyIn the case reported herein, the procedure had to be performed in an uncommon manner using extracorporeal membrane oxygenation, with excellent resultsExtracorporeal membrane oxygenation has been used to stabilise respiratory functions when extracting difficult upper airway foreign bodies; 42 such cases have been reported worldwideExtracorporeal membrane oxygenation can be used in resource-poor settings using ordinary, readily available polypropylene hollow fibre adult oxygenatorsPotential hazards of open thoracotomy and bronchotomy for foreign body extraction are discussedThe paper also justifies consideration of extracorporeal membrane oxygenation in exceptional upper airway emergency cases…”
Section: Discussionmentioning
confidence: 99%
“…Others have come to a similar conclusion. 5,6 When venovenous extracorporeal membrane oxygenation is available, and is delivered by adequately trained and experienced personnel, it should be considered as an option in the therapeutic management of difficult upper airway problems such as large, inhaled foreign bodies.…”
Background
Bronchoscopic removal of a foreign body is a common emergency procedure in paediatric otolaryngology. It is potentially life-threatening, as complete airway obstruction caused by the foreign body can lead to hypoxic cardiac arrest during the manipulation of the object.
Case report
This paper presents a child who had aspirated a foreign body that could not be extracted conventionally via rigid bronchoscopy in the first instance. Subsequently, it was extracted at repeat bronchoscopy under controlled respiratory conditions maintained by an extracorporeal gas exchange circuit – extracorporeal membrane oxygenation, using a polypropylene hollow fibre oxygenator commonly employed in cardiac surgery (rather than a more expensive polymethyl pentene oxygenator commonly used in extracorporeal membrane oxygenation).
Conclusion
Extracorporeal membrane oxygenation use can be considered in exceptional cases of upper airway emergencies, even in resource-poor settings, and can avoid more hazardous thoracotomy and bronchotomy procedures.
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