Use of THRIVE to maintain oxygenation during the management of an anticipated difficult airway and emergency tracheostomy

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We present a case of a patient with a large right-sided oropharyngeal tumor presenting for urgent panendoscopy and biopsy. Airway assessment revealed limited mouth opening, Mallampati score of 3 and limited jaw protrusion. Anesthetic plans included Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE), with intubation using a Bonfils Intubating Fiberscope (Karl Storz Endoscope, Tuttlingen, Germany). An awake fiberoptic intubation was deemed unsuitable due to severe patient anxiety and adequate vocal cord view on recent flexible nasendoscopy performed by the surgeon.Anesthesia was induced with full ASA monitoring and THRIVE using oxygen with a FiO2 1.0 at 70 l/min was then established. There was already bleeding inside the mouth prior to laryngoscopy. An attempt was made to lift the epiglottis but the tumor mass started to bleed, with a further unsuccessful intubation attempt from ongoing bleeding. After 3 further unsuccessful attempts at intubation by the surgeon using a rigid bronchoscope, a decision was made for an emergency tracheostomy. This was completed by 18 minutes post transfer into the operating room, with adequate time for patient positioning and sterility. The total apneic time was approximately 30 minutes; oxygen saturations were maintained at or above 99% and end-tidal CO2 after tracheostomy was 55mmHg.The use of THRIVE maintained apneic oxygenation during several failed intubation attempts, culminating in an emergency tracheostomy under controlled conditions. Through extension of the apneic window, THRIVE proved invaluable to our management of this difficult airway. It should also be noted that the decision for tracheostomy should be considered before the development of further airway compromise.

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