P058: AWAKE FIBEROPTIC AND RIGID BRONCHOSCOPY WITH THE AID OF NASAL CPAP
Matt T Gunst, MD1, Joseph C Goldstein, MD2; 1University of Florida, 2Malcom Randall VA Medical Center
Introduction: One of the safest and most conservative approaches to the anticipated difficult airway is the awake fiberoptic intubation. Patients with difficult airways often have obstructive airway disease with difficulties in oxygenating and/or ventilating. Airway Management Guidelines recommend pursuing opportunities to deliver supplemental oxygen throughout the process of difficult airway management. We present a case where the airway was prepared for fiberoptic assessment and rigid bronchoscopy with the assistance of a non-invasive nasal CPAP device to help maintain oxygenation in a patient with known severe tracheal stenosis.
Case Description: A 75-year-old male with a PMH of HTN, hyperlipidemia, and alcohol abuse who previously required tracheostomy following a MVA three years prior had been having increasing dyspnea on exertion with the reported sensation of “breathing through a straw”. He was noted to have an anticipated difficult airway with a mouth opening less than 3 fingerbreadths and limited neck extension, as well as baseline SpO2 of 96% on room air. Previous flexible bronchoscopy revealed an approximate 80% stenosis of the trachea at the level of the inferior thyroid cartilage, and the patient was scheduled for rigid bronchoscopy and tracheal dilation. In the preop area, a therapeutic alliance was built with the patient and he expressed understanding of the procedure. After oropharynx desiccation with 0.6 mg IV glycopyrrolate and topicalization with gargling of 2% viscous lidocaine solution plus 4% preservative free lidocaine via nebulizer, the patient was rolled back to the operating room while midazolam 1 mg IV was administered. Patient was positioned with his back elevated to roughly 45° and an intubating airway was inserted into the oropharynx. The nasal CPAP was applied with approximately 0.5% sevoflurane was administered, as well as ketamine 20 mg IV and fentanyl 75 mcg IV with the goal of maintaining spontaneous negative inspiratory force respirations. 4% lidocaine was administered through an epidural catheter that had been fed through the port of the fiberscope, and the fiberscope was advanced past the vocal cords and the stenotic trachea all the way to carina. After fiberoptic assessment a rigid bronchoscope was then passed through the vocal cord by the surgeon and the stenotic trachea was dilated via balloon in three attempts, all while ventilation was maintained through a side port. Only for portions of the rigid bronchoscope procedure was the nasal CPAP removed, with periods of apneic oxygenation for 10 seconds at a time during balloon dilation. The procedure lasted for less than 30 minutes and the oxygen saturation never dropped below 98%.
Discussion: Airway obstruction, in this case caused by post-tracheostomy tracheal stenosis, can cause hypoxemia especially when spontaneous, negative inspiratory force respirations are abolished. By having a participating patient who is sedated and using positive pressure ventilation through a nasal CPAP, oxygenation can be maximized during airway instrumentation with apneic periods.