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DP43: OBSTRUCTING UPPER-AIRWAY TUMOR: EMERGENCY MANAGEMENT OF AN ANTICIPATED DIFFICULT AIRWAY
Rojin Esmail, MD; Tamara Stojilkovic, DO; Gabriella Sardina, MD
HCA Kendall Hospital
Introduction/Background: Acute respiratory failure in a patient with a known obstructing pharyngeal mass represents an anticipated difficult airway with potential for rapid deterioration. The 2022 American Society of Anesthesiologists (ASA) Difficult Airway Guidelines emphasize early recognition of difficulty, team-based preparation with explicit backup plans, prioritization of oxygenation and ventilation, limiting repeated attempts with early escalation to alternative techniques, and prompt transition to an invasive airway when ventilation or oxygenation cannot be maintained. Awake tracheal intubation (ATI) is often preferred for anticipated difficult airways because it preserves spontaneous ventilation, but it requires effective topicalization and patient cooperation. When agitation, hypoxemia/hypercapnia, or impending respiratory failure makes an awake approach unsafe or impractical, management should prioritize oxygenation using the most reliable temporizing method (e.g., a supraglottic airway) while preparing for definitive rescue, with early progression to emergency front-of-neck access (eFONA) if noninvasive techniques fail(1,2).
Methods: This report describes the emergency airway management of a patient presenting with acute respiratory distress and stridor in the setting of a known pharyngeal mass. A multidisciplinary airway response was initiated, including anesthesiology, trauma surgery, and otolaryngology (ENT), with operating room preparation and escalation planning for invasive airway rescue.
Results: A 54-year-old female with COPD, tobacco use, and a known pharyngeal mass (previously declined treatment) presented to the emergency department with acute-on-chronic dyspnea. She was agitated, leaning forward, with audible stridor and an oxygen saturation of 94% on arrival. Anesthesiology was called to standby for potential emergency airway intervention due to concern for progressive upper-airway obstruction. Trauma surgery and ENT were notified for backup, and an operating room was readied.
Given impending respiratory failure and the patient’s agitation, awake tracheal intubation was not feasible. Induction was performed with etomidate and succinylcholine; videolaryngoscopy did not permit visualization of the vocal cords. Placement of a supraglottic airway, achieved an effective ventilation and enabling controlled transport to the operating room
In the OR, coordinated bronchoscopic inspection by anesthesia, trauma, and ENT through the LMA revealed friable oropharyngeal masses at the tongue base and posterior pharyngeal wall and severe anatomic distortion. Fiberoptic intubation through the LMA—and subsequently without it—failed due to obscured views and loss of identifiable laryngeal landmarks
Given persistent inability to secure a tracheal tube by noninvasive means, ENT performed emergent eFONA via cricothyrotomy. The cricothyroid membrane was incised with a #15 blade, dilated, and an endotracheal tube was placed over a bougie. Placement was confirmed by bronchoscopic visualization of tracheal rings and end-tidal CO2. The tube was secured, and the case was handed to trauma surgery for completion of a definitive tracheostomy. The patient maintained stable hemodynamics and oxygen saturation >97% throughout the procedure.
Discussion/Conclusion: This case highlights guideline-concordant management of a tumor-obstructed airway: early multidisciplinary mobilization, oxygenation-first stabilization with a supraglottic airway when awake intubation was not feasible, limited noninvasive attempts in a bloody/distorted airway, and rapid progression to eFONA when intubation failed. Early invasive-airway planning and timely escalation maintained oxygenation and enabled definitive airway control.