The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review

Abstract

While extracorporeal membrane oxygenation (ECMO) is an effective method of oxygenation for patients with respiratory failure, further refinement of its incorporation into airway guidelines is needed. We present a case of severe glottic stenosis from advanced thyroid carcinoma in which gas exchange was facilitated by veno-arterial ECMO prior to achieving a definitive airway. We also conducted a systematic review of the MEDLINE, EMBASE, CINAHL, and Web of Science databases, using the keywords "airway/ tracheal obstruction", "anesthesia", "extracorporeal", and "cardiopulmonary bypass" to identify reports where ECMO was initiated as the a priori method of oxygenation during difficult airway management.Thirty-six papers were retrieved discussing the use of ECMO or cardiopulmonary bypass (CPB) for the management of critical airway obstruction. Forty-five patients underwent pre-induction of anesthesia institution of CPB or ECMO for airway obstruction. The patients presenting with critical airway obstruction had a range of airway pathologies with tracheal tumours (31%), tracheal stenosis (20%), and head and neck cancers (20%) being the most common. All cases reported a favourable patient outcome with all patients surviving to hospital discharge without significant complications.While most practitioners are familiar with the fundamental airway techniques of bag-mask ventilation, supraglottic airway use, tracheal intubation, and front-of-neck airway access for oxygenation, these techniques have limitations in managing patients with pre-existing severe airway obstruction. The use of ECMO should be considered in patients with severe (or near-complete) airway obstruction secondary to anterior neck or tracheal disease. This approach can provide essential tissue oxygenation while attempts to secure a definitive airway are carried out in a controlled environment.

Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019

“…[7][8][9] Performing intubation or tracheotomy with the support of extracorporeal membrane oxygenation can also be considered. [10] 8. For patients with normal airway, awake intubation should be avoided and modified rapid sequence induction is recommended.…”

“…(3) A cricothyroidotomy may be performed using either a needle technique (a 4mm cricothyroidotomy kit) or a scalpel technique (a scalpel with number 10 blade, a bougie and a size 5.0mm -6.0 mm cuffed tracheal tube). 10. During the induction of anesthesia, hemodynamic instability is common.…”

Life-threatening giant esophageal neurofibroma with severe tracheal stenosis: a case report

“…The utility of ECMO in patients with severe airway obstruction was reported in the systematic review [19]. From the systematic review, all cases reported a favorable outcome with all patients surviving to hospital discharge without significant complications [19]. In our case, under the preparation of VV-ECMO when tracheal intubation fails, we were able to perform tracheal intubation safely and radical surgery thereafter.…”

“…Our case is the first report of a patient suffering from wheezing with severe tracheal stenosis and requiring quasi-urgent surgery. The utility of ECMO in patients with severe airway obstruction was reported in the systematic review [19]. From the systematic review, all cases reported a favorable outcome with all patients surviving to hospital discharge without significant complications [19].…”

Extrakorporale Membranoxygenierung in der Thoraxchirurgie: die Sicht des Anästhesisten

“…Von essenzieller Wichtigkeit ist die Vorhaltung eines in der Anwendung der ECMO erfahrenen Teams während des gesamten Behandlungszeitraums. Im Falle von globalen oder überwiegend hypoxämischen Gasaustauschstörungen erfolgt meist eine bikavale Kanülierung mit Einzellumenkanülen über eine Jugular-(17-19 French) und eine Femoralvene (19)(20)(21), um Blutflüsse von ca. 2-4 l/min zu ermöglichen.…”