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LETTER TO EDITOR
Year : 2021  |  Volume : 41  |  Issue : 3  |  Page : 158-160

Extracorporeal membrane oxygenation and awake fiberoptic intubation for the anesthetic management in a patient with a large intrathoracic goiter-induced severe tracheal stenosis


1 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
2 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei; Department of Anesthesiology, Chi Mei Medical Center, Tainan City; Department of Anesthesiology, Kaohsiung Medical University Chung Ho Memorial, Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of -Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
4 Division of Chest Surgery, Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan

Date of Submission09-Jun-2020
Date of Decision16-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication15-Aug-2020

Correspondence Address:
Dr. Bo-Feng Lin
Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei
Taiwan
Dr. Hou-Chuan Lai
Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_177_20

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How to cite this article:
Lin PA, Wu ZF, Lee JC, Huang TW, Lin BF, Lai HC. Extracorporeal membrane oxygenation and awake fiberoptic intubation for the anesthetic management in a patient with a large intrathoracic goiter-induced severe tracheal stenosis. J Med Sci 2021;41:158-60

How to cite this URL:
Lin PA, Wu ZF, Lee JC, Huang TW, Lin BF, Lai HC. Extracorporeal membrane oxygenation and awake fiberoptic intubation for the anesthetic management in a patient with a large intrathoracic goiter-induced severe tracheal stenosis. J Med Sci [serial online] 2021 [cited 2021 Jun 22];41:158-60. Available from: https://www.jmedscindmc.com/text.asp?2021/41/3/158/292361



To the Editor,

Administering general anesthesia (GA) to patients with a large intrathoracic goiter causing cardiorespiratory compression is always challenging and critical. A recent study reported anesthetic management of a patient with a large intrathoracic goiter with tracheal compression under extracorporeal membrane oxygenation (ECMO) before GA induction.[1] To the best of our knowledge, we managed a patient with the most severe tracheal obstruction caused by a large intrathoracic goiter.

A 69-year-old female (ASA III; height, 155 cm; weight, 48 kg) presented with progressive dyspnea for 6 months that was aggravated when placed in the supine position and was scheduled for total thyroidectomy. She had rheumatoid arthritis, for which she received medication. Preoperative laboratory tests revealed normal findings, whereas preoperative chest computed tomography demonstrated a massive goiter extending into the thoracic cavity and causing extrinsic airway compression; the lumen diameter at the narrowest portion of the trachea was 10.1 mm × 1.4 mm [Figure 1], and the distance from the narrowest point to the carina was 8.9 cm. However, no hemodynamic instability was observed. The patient was not premedicated. A hemodynamic monitoring system (electrocardiography, noninvasive arterial blood pressure measurement, and pulse oximetry) was set up. Her initial vital signs were as follows: blood pressure of 154/78 mmHg, regular sinus rhythm with a heart rate of 91 beats/minute, and peripheral oxygen saturation (SpO2) of 98%. Using a facemask, the patient was preoxygenated with 100% oxygen at a flow rate of 6 L/min. Considering the possibility of total airway obstruction during GA induction, the patient received a combination of venovenous ECMO and awake fiberoptic intubation with topical anesthesia. Nasotracheal intubation was carried out using an internal diameter of a 6.0-mm nasal-cuffed endotracheal tube (Shiley™ oral/nasal tracheal tube cuffed; Covidien, Dublin, Ireland) under fiberoptic bronchoscopic guidance (outside diameter, 3.5 mm; FI-10BS Pentax™ Corporation, Tokyo, Japan). Fortunately, the nasotracheal tube was advanced beyond the narrowest portion of the trachea, and the 26-cm mark was fixed at the right wing of the nose. The patient was mechanically ventilated under the following parameters: tidal volume, 6–8 mL/kg; respiratory rate, 10–12 times/min; end-tidal carbon dioxide partial pressure, 35–40 mmHg; peak inspiratory pressure, 10–20 cmH2O. Anesthesia was maintained with 2%–4% sevoflurane in 50% oxygen at a flow rate of 1 L/min. The patient's hemodynamics were stable, and SpO2 was 99%–100% during the surgery. The surgery took 402 min and was performed smoothly without any complications. She was transferred to the intensive care unit after the surgery. The absence of tracheomalacia was confirmed via fiberoptic bronchoscopy, and subsequently, ECMO was discontinued on the 1st postoperative day. On the 4th postoperative day, the absence of laryngeal edema was confirmed using a video-laryngoscope, and the cuff-leak test showed a cuff-leak volume of >150 mL, and extubation was performed uneventfully. After extubation, chest radiograph exhibited restoration of the tracheal lumen [Figure 2]. On the 5th day after surgery, she was transferred to the general ward. Eight days after surgery, the patient was discharged without any sequelae. The histopathological findings revealed a well-defined nodular lesion with some dilated thyroid follicles.
Figure 1: Preoperative chest computed tomography showing that the diameter at the narrowest portion of the trachea was 10.1 mm × 1.4 mm

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Figure 2: Postoperative chest radiograph showing restoration of the tracheal lumen

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Jeong et al.[1] reported a case of a patient whose lumen diameter at the narrowest portion of the trachea was 26.0 mm × 4.3 mm, and Tan and Esa[2] also reported a case of another patient whose lumen diameter at the narrowest portion of the trachea was 12.0 mm × 6.0 mm. The other case reports only reported goiter sizes without stating the lumen diameter at the narrowest portion of the trachea.[3],[4] In our case, the lumen diameter at the narrowest portion of the trachea was 10.1 mm × 1.4 mm, which might be the most severe tracheal compression case reported in the literature.

When GA is required in a patient with a mediastinal mass, awake intubation is safer because total airway obstruction can occur after the induction of anesthesia.[5] However, there are no standard protocols for guiding perioperative procedures in patients with a large intrathoracic goiter causing cardiorespiratory compression.[1] Moreover, ECMO is an alternative life support technique for maintaining both cardiac and respiratory functions by employing mechanical devices.[6] Consistent with the case report published by Jeong et al.,[1] in the present case, GA was induced by a combination of ECMO and awake nasotracheal fiberoptic intubation because we could not ensure airway patency throughout surgical procedure. In addition, ECMO was advised and set up by an experienced cardiovascular surgeon during GA induction for avoiding fatal complications related to potential airway collapse during anesthesia. In case of cardiopulmonary decompensation, at least 5–10 min is required for cannulation and establishment of adequate circulation and oxygenation despite the presence of a primed pump and prep team. Such delays can lead to severe adverse neurological sequelae as well as death.[7]

In conclusion, we highlight that the combination of ECMO establishment and awake fiberoptic intubation during GA induction is a safe and effective strategy for maintaining oxygenation in a patient with severe tracheal compression.

Acknowledgment

We thank the patient for signing the informed consent for publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jeong YI, Jun IG, Ha SS, Kwon HJ, Lee YM. Extracorporeal membrane oxygenation for the anesthetic management of a patient with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms: A case report. Medicine (Baltimore) 2019;98:e17650.  Back to cited text no. 1
    
2.
Tan PC, Esa N. Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: The challenges imposed-A case report. Korean J Anesthesiol 2012;62:474-8.  Back to cited text no. 2
    
3.
Tsakiridis K, Visouli AN, Zarogoulidis P, Karapantzos E, Mpakas A, Machairiotis N, et al. Resection of a giant bilateral retrovascular intrathoracic goiter causing severe upper airway obstruction, 2 years after subtotal thyroidectomy: A case report and review of the literature. J Thorac Dis 2012;4 Suppl 1:41-8.  Back to cited text no. 3
    
4.
Ket S, Ozbudak O, Ozdemir T, Dertsiz L. Acute respiratory failure and tracheal obstruction in patients with posterior giant mediastinal (intrathoracic) goiter. Interact Cardiovasc Thorac Surg 2004;3:174-5.  Back to cited text no. 4
    
5.
Asai T. Emergency cardiopulmonary bypass in a patient with a mediastinal mass. Anaesthesia 2007;62:859-60.  Back to cited text no. 5
    
6.
Malpas G, Hung O, Gilchrist A, Wong C, Kent B, Hirsch GM, et al. The use of extracorporeal membrane oxygenation in the anticipated difficult airway: A case report and systematic review. Can J Anaesth 2018;65:685-97.  Back to cited text no. 6
    
7.
Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol 2009;26:627-32.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2]



 

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