A patient presented to Accident and Emergency with a post operative bleed 3 days after a hemithyroidectomy. Nasendoscopy showed a patent upper airway. The senior anaesthetic resident discussed the case with their consultant. The patient’s airway assessment was favourable (MP1) and they agreed that the resident would use videolaryngoscopy for intubation, using a supraglottic airway as Plan B, with fibreoptic available. The consultant surgeon was also happy to let their registrar continue in their absence.

The resident was unable to intubate or ventilate through a SGA. Both the resident and an on-site ITU consultant were unable to get emergency front of neck access [eFONA] via the open neck wound. After a second failed attempt at eFONA the ICU consultant managed to intubate orally using laryngoscopy and a bougie passed blindly.

The patient was swiftly re-oxygenated and vital signs returned to acceptable levels (5 mins of inability to ventilate, sats dropped to 11%) There was no cardiac arrest.

After a suitable period of stability, the patient was moved to the operating theatre and surgery took place.

Commentary

This case highlights the need for careful planning for patients with an anticipated difficult airway, even when time is against you. This includes having the correct team, expertise and kit present. 

On a technical note of best practice:

• We are moving from pre- to per-oxygenation to prolong the apnoeic window, especially when intubation is predicted to be difficult. Use of high flow nasal oxygen is therefore encouraged
• Evaluate for airway compromise and evacuate haematoma if needed
• For intubation: small tubes with introducers may offer more success
• Sustained exhaled CO₂ (alongside visualisation) is to be used to confirm tube placement in all circumstances.

Awake techniques maybe preferable in such cases. Please see references to the Difficult Airway Society’s guidelines for awake tracheal intubation¹ and the checklist² that highlights which team members should be on site and identifies who should perform eFONA should the need arise. 

For full airway management of haematoma after thyroid surgery readers are referred to   the multidisciplinary consensus guidelines from the Difficult Airway Society, British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery.³

References:

1. Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaes. 2020; 75(4): 509-28
2. Difficult Airway Society Checklist for Awake Tracheal Intubation. Anaes. 2020; 75(4), Supplement
3. Iliff, HA, El-Boghadadly K, Ahmad I, et al. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaes. 2020; 77(1): 82-95