Introduction
This case report details an incident of a difficult airway in a coagulopathic patient with extensive lingual bleeding and hematoma formation who also was DNR, with
discussion of subsequent airway management and ethical considerations. A difficult airway is defined as the inability of a conventionally-trained anesthesiologist to either mask ventilate, perform tracheal intubation, or both. An enormous lingual hematoma obstructing the mouth would itself present a significant airway challenge. Ablation of spontaneous respiration can create a situation where intubation and mask ventilation is impossible.
Case report
A 79 year old Tagalog speaking female with end stage renal disease on hemodialysis, atrial fibrillation, hypertension, and diabetes presented with altered mental status from uremia/metabolic disturbances after a missed dialysis run, as well as possible infection. On admission, she was noted to have edema of the lower lip and two ulcerative lesions on her oral mucosa of unclear etiology. The day after admission she was found with copious bleeding from her mouth, with a large lingual mass protruding, and in respiratory distress with desaturations into the 70s on room air. She was placed on supplemental oxygen which improved her hypoxia. Emergent intubation for airway protection was requested. Using an interpreter she consented to intubation. Her coagulopathy was reversed. The difficult airway cart was made available with cricothyroitomy equipment on standby. Then using small boluses of propofol the patient was lightly sedated without ablation of spontaneous ventilation. Using a nasal airway, the fiberoptic bronchoscope was successfully navigated into the trachea. The nasal airway was then removed and a 6.0 mm endotracheal tube was inserted in the right nares. Unfortunately fiberoptic bronchoscopy was unsuccessful and was aborted when her oxygen saturation reached 92%. The patient was transported to the operating room for further airway management and exploration of her bleeding mouth. The patient remained spontaneously ventilating and oxygen saturations remained > 91%. In the operating room, patient was mask induced with preservation of spontaneous ventilation. A third attempt at fiberoptic endotracheal intubation was successful. Subsequently a large clot was cleared from her mouth and the source of bleeding was identified as an anterior tongue ulceration thought to be a venous bleed. The area was cauterized and oversewn with hemostasis achieved.
Discussion
The difficult airway can arise suddenly and progress rapidly to respiratory failure. It requires quick decision making and also thorough preparation. These situations can also be complicated by ethical considerations such as advanced directives in medically complex patients. This case further highlights the value of establishing clear thresholds and team member roles during critical situations, such as tenuous airway management. Lastly maintaining spontaneous ventilation proved key to success for this patient. The case report demonstrates the importance of the skilled airway practioner in management of the difficult airway.
