Wendy Wieneke, RRT, RN, MSN, NRP, CEN, CCRN, CFRN and Alyssa Diroff, RN, EMT-P, I/C, CEN, CCRN, CFRN – Survival Flight Nurses
Case Presentation:
This is a 60-year-old male diagnosed with right neck cancer approximately 3 years ago, but who sought no treatment for unspecified reasons. On the date of encounter, he presents to a small local Emergency Department at the prompting of his family reporting a “4-day history of a new tumor on the left side of his neck that is oozing large amounts of fluid”. The patient endorses dysphagia, a change in his voice, the need for a soft diet, and the tripod position being of greatest comfort. The patient is being transferred to a tertiary facility for ENT/oncological evaluation and treatment.
Intake Information:
The flight team was called by the Super AOD (a physician that oversees all admissions and transfers in the age of COVID-19) who stated there was a patient in another ED with significant airway issues/compromise that needed transfer. He is currently on room air with SpO2’s in the mid- to high-90’s, speaking in full sentences, and appears in minimal to no distress as long as he can maintain the tripod position. A CT scan revealed a 13.3×9.5 cm right neck soft tissue mass with a medial shift and partial right common carotid artery occlusion and complete occlusion of his right internal jugular. A left neck mass was also noted with a fistula and communication to the skin. A third soft tissue mass was noted involving the supraglottic tissue and pharynx resulting in severe narrowing of the airway. Given the patient’s high probability of decompensation and the potential for surgical cricothyrotomy intervention, our flight team was being requested given our advanced airway skill set.
Prior to Departure:
Weather conditions precluded us from flying, so the wait time for an ambulance to arrive was utilized to develop a plan. A few things about the report stood out to us:
- The medial shift of neck structures making location of landmarks difficult to impossible and complicating a surgical cric procedure by displacing vasculature into the surgical field.
- The severe narrowing of the airway coupled with the medial shift made intubation from the top difficult at best and likely impossible.
- We had a 45-minute ground transport time.
Interventions we Considered:
- Supplemental oxygen in any form. The patient was on room air with acceptable SpO2 levels so we could start at nasal cannula and work our way to non-rebreather mask if oxygenation became compromised.
- BiPap. We were undecided if this would help given the supraglottic/pharynx mass. The positive pressure could have stented open the airway or pushed the mass down further leading to complete airway blockage.
- LMA. Again, we were undecided if this would help or further compromise airway patency, but both agreed we would have it out and at the ready for trial.
- Intubation. We both felt this was risky at best. With advanced neck cancer, we were unsure if the surrounding tissues were friable increasing the odds of perforation. Additionally, the medial shift in structures made advancement of the tube certainly difficult if not impossible. One option we considered was intubation with a small ETT (#5.0 or #5.5) which may have advanced in the trachea easier and caused less tissue damage. Cyr et. al. (2020) describes a paraglossal approach where the laryngoscope is inserted in the left corner of the mouth and the blade captures the tongue at an approximate 60o angle. The view is somewhat obscured but should allow for the insertion of a tracheal tube introducer. This procedure should be done via direct or video-assisted direct laryngoscopy.
- Needle cricothyrotomy with jet insufflator. While the idea of using the jet insufflator is frightening, we both determined that it could potentially be our best way to oxygenate this patient if other means of securing an airway failed.
- Surgical cricothyrotomy. And the options just got more frightening as we moved down the algorithm. This particular airway intervention was given a great deal of discussion. A shift in structures would make locating landmarks difficult. Additionally, a shift in all structures meant a shift in cervical vasculature as well making a midline vertical incision risky due to the potential for vessel interruption and excessive bleeding. Altering the location of our incision was discussed, but liability concerns over performing a procedure outside of our protocols and what we are taught arose. In the end, a call to our medical director was made for clarification.
There is a growing body of evidence advocating for the use of point of care ultrasound (POCUS) in order to locate key anatomical structures. Just as performing a blind pericardiocentesis or central line insertion has gone out of favor with the advent of ultrasound-guided procedures, so will the performance of a surgical airway on “feel” alone. Our team is currently learning this technique but had not yet become proficient in it during the writing of this discussion piece.
Arrival and Patient Assessment:
Arrival at the bedside found the patient as reported: sitting on the side of the bed in the tripod position, speaking in full sentences, minimal to no distress, HR- 89, 135/91, 96% on room air, and f -19. Assessment revealed a Malampatti of III to IV with minimal ability to open mouth and a notably enlarged tongue. Further examination of his neck revealed the inability to palpate tracheal rings rendering landmark identification impossible. A review of his neck films was done by one member of the flight crew and the referring physician.
Despite the films and the assessment findings, the flight crew proceeded with the transport. The patient remained awake, alert, talking in full sentences, and in minimal distress throughout the transport. No supplemental oxygen or airway interventions were required.
Patient Follow-Up:
Shortly after arrival, the patient was taken to the operating room for an awake fiberoptic tracheostomy and tissue biopsy procedure. The cancer was found to have metastasized to his lungs and bones. Palliative radiation therapy was offered. The patient was discharged with home care services in place 10 days after transport.
Discussion Points:
- Should we or should we not transport this patient?
- It is impossible to definitively say we should or should not have transported this patient without a definitive airway in place prior to departure. In fact, discussions with physicians and flight nurse colleagues within our own program yielded a variety of answers and thoughts. In the end, the decision lies with each individual crew and team member based on their level of training and proficiency/comfort with airway techniques. Prior to arrival, we thoroughly discussed the need to both be comfortable speaking up if we felt transport without a definitive airway was not safe for the patient.
- Do we alter how we perform a procedure based on patient anatomy/presentation?
- As previously stated, a call to our medical director was made to discuss surgical airway techniques and whether or not we should make a midline incision or alter our position. We were instructed to perform the procedure as we have always been taught (midline vertical incision) to improve success. The point here is simple: When in doubt about how to proceed or if you are considering veering from protocol or procedure expectations, ALWAYS seek medical direction/control first!
- Which airway intervention would have been best?
- This also is difficult to say. Our plan was to start with supplemental oxygen and work our way through the adjuncts until we found one that was able to adequately support oxygenation. Thankfully, no airway interventions were required, but it should be noted and cannot be overstated that every airway adjunct we had was out, prepped, and ready for use in the event of acute patient decompensation!
Critical Care Transport Providers are trained in advanced airway techniques for obvious reasons. Nonetheless, even the most highly trained clinicians need to maintain vigilance and recognize cases that either test or exceed those skills. The need to talk through assessment findings and develop a safe plan of care cannot be overstressed. When in doubt, contact and consult with medical direction. Remember that sometimes the best thing we can do for our patients is to know and respect our own limitations.
References:
Adi, O., Fong, C. P., Sum, K. M., & Ahmad, A. H. (2020). Usage of airway ultrasound as an assessment and prediction tool of a difficult airway management. The American journal of emergency medicine.
Cyr, K. L., Orestes, M. I., Godoy, D. C. G., & Adams, M. A. (2020). Left Paraglossal Approach for Airway Management of Patient With Large Neck Mass in an Austere Environment: A Case Report. A&A Practice, 14(7), e01229.
Gottlieb, M., Holladay, D., Burns, K. M., Nakitende, D., & Bailitz, J. (2019). Ultrasound for airway management: an evidence-based review for the emergency clinician. The American journal of emergency medicine.