Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma: A case report and literature review

I-Liang Liu; An-Hsun Chou; Chien-Hung Chiu; Yu-Ting Cheng; Huan-Tang Lin

doi:10.12998/wjcc.v10.i35.13088

Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma: A case report and literature review

World J Clin Cases. 2022 Dec 16;10(35):13088-13098. doi: 10.12998/wjcc.v10.i35.13088.

Authors

I-Liang Liu¹, An-Hsun Chou^{1

2}, Chien-Hung Chiu³, Yu-Ting Cheng³, Huan-Tang Lin^{1

2

4}

Affiliations

¹ Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan.
² College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
³ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan.
⁴ Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan. sanctuary12@cgmh.org.tw.

Abstract

Background: Anesthesia for tracheal tumor resection is challenging, particularly in patients with a difficult upper airway. We report a case of a difficult upper airway with a metastatic tracheal tumor causing near-total left bronchial obstruction and requiring emergency tracheostomy and venovenous extracorporeal membrane oxygenation (VV-ECMO) support for rigid bronchoscopy-assisted tumor resection.

Case summary: A 41-year-old man with a history of right retromolar melanoma treated by tumor excision and myocutaneous flap reconstruction developed progressive dyspnea on exertion and syncope episodes. Chest computed tomography revealed a 3.0-cm tracheal mass at the carinal level, causing 90% tracheal lumen obstruction. Flexible bronchoscopy revealed a pigmented tracheal mass at the carinal level causing critical carinal obstruction. Because of aggravated symptoms, emergency rigid bronchoscopy for tumor resection and tracheal stenting were planned with standby VV-ECMO. Due to limited mouth opening, tracheostomy was necessary for rigid bronchoscopy access. While transferring the patient to the operating table, sudden desaturation occurred and awake fiberoptic nasotracheal intubation was performed for ventilation support. Femoral and internal jugular vein were catheterized to facilitate possible VV-ECMO deployment. During tracheostomy, progressive desaturation developed and VV-ECMO was instituted immediately. After tumor resection and tracheal stenting, VV-ECMO was weaned smoothly, and the patient was sent for intensive postoperative care. Two days later, he was transferred to the ward for palliative immunotherapy and subsequently discharged uneventfully.

Conclusion: In a difficult airway patient with severe airway obstruction, emergency tracheostomy for rigid bronchoscopy access and standby VV-ECMO can be life-saving, and ECMO can be weaned smoothly after tumor excision. During anesthesia for patients with tracheal tumors causing critical airway obstruction, spontaneous ventilation should be maintained at least initially, and ECMO deployment should be prepared for high-risk patients, such as those with obstructive symptoms, obstructed tracheal lumen > 50%, or distal trachea location.

Keywords: Case report; Extracorporeal membrane oxygenation; Melanoma; Tracheal tumor; Tracheostomy.

Publication types

Case Reports