(1060) Beyond the Difficult Airway Algorithm: The Impossible Airway

Introduction: Difficult airways in the ICU are common and require careful preparation that considers the location and etiology of the obstruction; ex, a supraglottic swelling can be managed with a bougie and video-endoscopy whereas a subglottic stenosis might require a tracheostomy. We describe a case of mid-tracheal stenosis due to malignant compression from an anterior mediastinal mass that presents a level of difficulty; the impossible airway, that demands a multi-disciplinary approach.

Description: A 38 year-old man was admitted for acute respiratory failure with stridor. CT Chest was remarkable for anterior mediastinal mass with significant tracheal narrowing, and he was referred for CT-guided biopsy however the procedure was aborted after he developed worsening stridor and was transferred to the ICU. Anticipating a difficult airway, we brought the difficult airway cart, secondary critical care support, consulted to general surgery and cardiothoracic surgery for urgent ECMO. ECMO guidewires (or rescue lines) were planned to allow transition to the circuit if necessary, however, the patient decompensated and required rapid sequence intubation which was successful.

A tissue biopsy diagnosed large B-Cell lymphoma for which induction chemotherapy was started. Tracheal stent placement and balloon dilation was planned by interventional pulmonology and cardiothoracic surgery placed ECMO rescue lines in the OR prior to the procedure. The stent was deployed without complication and the ECMO lines were never used, within a few days the patient was extubated. A few months later, CT showed a shrinking mass, and the patient was recovering.

Discussion: Most difficult airways are successfully managed in the modern ICU; however, a mid-thoracic stenosis will defy even the best operator and a multi-disciplinary approach is mandatory. Where available and time permits, we recommend a Cardiothoracic consult and placement of ECMO rescue lines prior to an intubation attempt. These guidewires permit rapid transition to ECMO, the goal being a short period on ECMO as stents or induction chemotherapy is started. When faced with the impossible airway, and high risk of terminal airway loss, include ECMO early in your planning.