Background:
Airway obstruction is a common problem that anesthesiologists deal with on a daily basis; however, it is usually in the context of obstructive sleep apnea or residual anesthetic agents causing relaxation of the upper airway musculature. It is less frequent that the anesthesiologist is called upon to aid a patient presenting from home for airway obstruction in the emergency department.
Case Description:
A 61 year-old 6’3”, 101kg male with a past medical history of a mandibular hemangioma and sarcoidosis presents with upper airway obstruction.
The patient had undergone 3 tracheostomies, which were all later decannulated. The first was status-post surgical excision of the mandibular hemangioma. The 2nd occurred after a respiratory arrest and the third after surgical excision of subglottic lesions causing subglottic stenosis, which were thought to be from sarcoidosis with tracheal involvement. After this the patient reportedly recovered to a stable state of health with good exercise tolerance.
Two years later he presented to the emergency department acutely short of breath after coughing at home. The patient was seen by otolaryngology. Nasal video-laryngoscopy revealed crusted lesions thought to be tissue extending from the nasal cavity to the supra-glottis. The patient’s vocal cords and a subglottic lesion of unspecified size were visualized. The glottis opening was reportedly only approximately 2mm and there was no visible foreign object.
The patient had biphasic stridor. His lungs were clear and his oxygen saturation was 99% on 10 liters per minute of supplemental oxygen via simple facemask. The patient was oriented and able to utter short 1-2 word phrases. Helium 80% - Oxygen 20% (Heliox) was started via a partial re-breather facemask with resolution of the stridor and the patient was transported to the operating room with full monitors where a successful awake tracheostomy was performed. The patient tolerated the procedure well. In the post-anesthesia care unit he was alert and comfortable, breathing spontaneously on tracheostomy mask.
Discussion:
This case demonstrates the importance of understanding airway obstruction physiology. Anesthesiologists should be equipped to use respiratory adjuncts outside the operating room such as Heliox and to be comfortable with the use of various non-invasive oxygen delivery devices.
