Surviving and THRIVE-ing the difficult airway: Gaining calm, control, and time during an emergent tracheostomy (Preview)

Nicole Arkin, MD¹; Erin Bushell, MD¹

¹Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, U.S.A.

Introduction

Patients with the history of head and neck cancer often present with some of the most challenging airways for the anesthesiologist.^1-3 Although tracheostomy may be performed primarily in some of these cases, often nasal or oro-tracheal intubation is requested by the surgeon initially, to minimize airway trauma and tumor disturbance.⁴ The surgical airway is also the final pathway of the American Society of Anesthesiologists (ASA) difficult airway algorithm, and in many cases is employed hastily, amidst the chaos of difficult or impossible ventilation and oxygenation. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE)⁵ can maintain oxygenation, improve V/Q matching during apnea, assist with alveolar recruitment, and reduce anatomic shunting, ultimately providing additional time in which to secure a difficult airway. We present a case in which THRIVE was successfully used to maintain oxygenation in a patient with a difficult airway undergoing a technically challenging emergent surgical airway rescue.

Case Presentation

A 57 year-old, ASA class 3 male presented for radical laryngectomy. He had a history of heavy tobacco use and recently diagnosed squamous cell carcinoma (SCC) of the larynx that recurred despite undergoing chemotherapy and radiation six months prior.

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