P044: A LUMP IN THE BACK OF THE THROAT
Joohi Khan1; Amy Burns2; 1Kendall regional medical center; 2Wolf son children's hospital
Introduction: A difficult airway is defined as a situation in which a clinician experiences difficulty with face mask ventilation, laryngoscopy, or intubation. majority of difficult pediatric airways (difficulty with mask ventilation or intubation) can be identified preoperatively, but many are unanticipated.
Case Description: 6 yo female presented to the ER with sore throat and progressive difficulty breathing x 6 hours. The day of presentation the patients mother at bedside stated that she noticed her daughter was having to sit forward. When the patient was seen in the emergency room, she was sitting forward in her bed, was not speaking and had her neck slightly extended. She was breathing hoarsely, consistent with stridor. Airway assessment was notable for a mallampati 4, small mouth opening of two finger-breadths width, but adequate thyromental distance and adequate mandibular protrusion. Significant neck swelling was noted with bilateral lymphadenopathy. CT of the neck was reviewed with ENT, as well as the intensivist. Airway was patent. Radiology read as a normal epiglottis with lymphadenopathypresent. Parents at bedside were made aware of the situation and the possibility of a surgical airway was explained. Intravenous access was obtained and the decision was made to attempt securing of the airway in the operating room. Plan of securing the airway was discussed between ENT and the pediatric anesthesiologist, with both being present in the operating room at time of induction. The patient was brought into the operating room and transferred to the operating room table, she preferred to remain in a sitting position and preoxygenation was started. Anxiolysis obtained with midazolam. After preoxygenation, a combined gentle intravenous and inhalational induction was started with use of ketamine, precedex and sevoflurane. She was placed in a supine position with maintenance of spontaneous ventilation. Mask ventilation was attempted with and without an oral airway but there was inconsistent end tidal co2. Indirect laryngoscopy was attempted with inability to pass because the patient was not deep enough to tolerate. ketamine was given and patient’s oxygen saturation started to fall and bradycardia was noted for which atropine was given. It was apparent after laryngoscopy that intubation from above would not be possible. After further attempts to mask ventilate with inconsistent end tidal co2 and continuous desaturation, the decision was made to perform tracheostomy. An oral airway was placed and mask ventilation was continued to be attempted with occasional end tidal co2. A surgical airway was secured and confirmed followed by oxygen saturation improvement. A scope was inserted into the upper airway and it was noted that there was a round mass completely obstructing the glottic opening.
Discussion: Whenever a difficult airway is anticipated, one should make sure the proper equipment and adjuncts are in place which can include a fiberoptic scope as well as surgical assistance for the possibility of a surgical airway. Chin lift, jaw thrust, oral or nasopharyngeal airways, two-person mask ventilation, and continuous positive airway pressure (CPAP) with a tight mask seal are all strategies for alleviating anatomical obstruction during mask ventilation, similar to adults. Other devices used for ventilation can include supraglottic airway, or a nasopharyngeal airway. Intubation may be attempted with direct and indirect laryngoscopy.