It is definitely a difficult scenario, and all effort should be made to deal with the unexpected complications.The management should be by an expert anesthetist with experienced assistance and Experinced ENT surgeon standby. The management should be in theatre with full preparations. After explaining the procedure to the fasted patien. Induction is started with sevoflurane in O2, you have to be patient, it will take long time, at any time if the patient has got obstruction he or she will wake up immediately, you wait till the patient is deeply anesthetized then try to do laryngoscopy, if that is ok then intubate if the patient is not deeply anesthetized wait more, if it is impossible to intubate then the other alternative is surgical tracheostomy under local anesthesia by experienced surgeon,be prepared any time for quick cricothyrotomy as will

Very comprehensive. Though I suppose it mostly depends on the mass being supra or infra-glottic. They would be somehow differently treated. Preoperative X-ray and specially CT scan images are extremely helpful in giving the anesthesiologist clues on the degree of the obstruction or even existence of deviation. Administration of volatile agents especially sevo is completely safe. However, due to lack of the agent or its being expensive, it is difficult to be found in the hospitals of the developing countries. Here are two other techniques that I use:

1. Performing awake intubation either with administration of topical anesthetics and IV premedication or its safer and more classic approach i.e performance of three nerve blocks and intra-laryngeal lidocaine.

2. Another technique which I use for smaller masses is performing induction with remifentanyl+propofol in small doses so that the patient would not suffer prolomged apnea.

Thanks very much for your comments. Completely agree that detailed pre-operative investigation to determine the extent of the problem is very desirable (CT scan, X-ray and nase-endoscopic review). This, however, is not always possible in patient who has got stridor and is not able to lie flat.

Gaseous induction has been traditionally recommended. My experience with it is that when the obstruction is not critical and you are able to achieve adequate levels of anesthesia than it works very well indeed. When the level of obstruction is critical, however, loss of patient airway happens well before adequate level of anestheisa; so you have lost an airway and your laryngoscopy fails due to inadequate anaesthesia. Recovery from this is uncertain as the volatile agent is not going to be exhaled as there is no airway, so we are relying on re-destribution into other tissues than brain (plus metabolism) for patient to wake up. Emergency surgical airway may bail you out, but is not desirable part of the airway management strategy.

What about awake airway management one of the following: awake fibreoptic intubation, awake Macintosh or Videloryngoscope aided intubation, awake tracheostomy?

Yes indeed. I just wanted to find out what do you think about possible criticism of the technique, such as 'cork in a bottle' effect once the fibreoptic scope is in situ (loss of airway due to the fibrescope obstructing narrow airway), loss of airway due to administration of local anaesthetic, uncertain success with railroading over the scope as it is blind technique (if stuck you would not know where is the problem) and the tumour/mass may make railroading over the scope impossible.

I am really very interested in hearing about managing these patients by awake fiberoptic technique, my opinion, even with a good deal of experience, this may end up with difficult scenarios in obstructed patient with distorted airway anatomy.

All of the above-mentioned techniques used and suggested by dear colleagues are great. But we should all remember that the procedure is performed either by ENT surgeons or Thoracic surgeons both of which are experienced in performing urgent tracheostomy. This is an absolute relief to the anesthesiologist as the last resource. I had a similar case in which the patient went into apnea with a very simple premedication and the airway could not be secured. Fortunately for such patients premedication is performed in the operating room in our center and in a few seconds the surgeon performed the tracheostomy.

For me awake airway management is the option of choice in this scenario.

Awake airway management will keep a number of options still open (i.e. awake tracheostomy) , providing you are sensible enough to pull back on time if the chosen method is not working. And stopping is much easier with awake techniques that with GA or sedation techniques. Awake fibreoptic intubation would not be my first choice in majority of patients with stridor.

My method of choice would be using awake videolaryngoscope guided intubation. By selecting videolaryngoscope with a tube channel such as Pentax AirwayScope, you can have wide angle view of the area and direct the tube having a full view of all the landmarks. Another important advantage of this technique is to do with the advancing a tube into the narrowed airway. This makes patient's breathing easier as you are advancing the tube passed the obstruction. for a patient with stridor. Used this technique in five patients so far successfully.

Nothing much to disagree with from any of the previous responses. However, whilst every trainee anaesthetist may immediately respond with awake fibre optic intubation as the gold standard I believe that this is e gold ideal, not standard, as these instruments are expensive, liable to breakages, seldom purchased in sufficient numbers to make them "everyday" instruments. The danger then is trying to use an unfamiliar tool in inappropriate circumstances. Not everyone will agree with these comments, which is fine. The second point is that a cardinal rule is never put yourself in a situation you cannot get out of. Which brings one to the point of cant intubate, can't ventilate. Current recommendations are that you should give a relaxant, something I strongly disagree with. Has anybody else a view on this aspect?

As an after thought I used to work with an anaesthetist in Africa who gave thiopentone and scoline to every one of his upper airway obstructions and never came to grief. This supports the previous response - it does not matter what technique you use, as long as you are good at it.

Iwould like to share my experience also. Due to legal liability I think the best way is to stick with guidelines, that ASA or DAS guidelines where in predicted difficulty only awake management is proposed. I usually perform adequate local anaesthesia and then I try to perform one laryngoscopic attempt using the Airtraq laryngoscope. If there is such a narrow glottis that the tube cannot pass, I revert to surgical airway. Up to now I have not failed to manage any obstruction. I usually have the choice of fibeeoptics but from experience it is time consuming and there is a possibility of totally obstructing the already narrow glottis.

Dear Zogogiannis,

I am not aware of DAS guidelines regarding anticipated difficult airway, could you please attach them, I did not find them in the website, thanks.

I totally agree with the idea of not using muscle relaxation in such patients. No matter how experienced you are in airway management, critical conditions could arise in using muscle relaxation in such cases. Eric is absolutely right on the idea of fiber-optic. Younger trainee do not get the chance to master it enough to be used in critical situations. I had a very interesting case for which I was called to one of the wards in our hospital. The patient was in respiratory failure due to subglottic tumor. I tried to intubate the patient, I used the smallest tube possible but the tube would not pass further the vocal cords due to the infraglottic tumor and the saturation started dropping dramatically. So without any hesitation I my self pulled the patient to the OR while others were calling for help and the surgeons. What I want to highlight here is that not having any problem until now would not guarantee you for the rest of your cases.

Dear Ghazi,

you are right that DAS does not propose directly awake intubation about anticipated difficult airway, on the other hand ASA does. DAS guidelines state clearly (Henderson et al. , Anaesthesia 2004) that they are not applicable to pediatric patients, obstertric patients or cases with upper airway obstruction. Also in Update in Anaesthesia Vol 25 num 2 Dec 2009 it is recommended that in case of possible inability to mask ventilate such a patient awake techniques are preferable.

As Dr. Anthony Schapera mentioned, these educational programs for the trainees are available in the U.S and developed countries. However, I suppose the settings in which we (in the developing countries) work would not provide such facilities in all centers and specialists have to stick to the conventional approaches.

I think surgical management is the only appropriate, as the tumor is going to increase with time. So this is the only permanent solution, because establishing the airway with a narrow endotracheal tube with the danger of obstruction or dislocation is rather risky.

Please see guidelines on EAMS website www.eamsonline.org

Awake fiberoptic to view the situation, and then even it is better to go safe and ask an ENT surgeon for opinion and possibly tracheostomy. Please beware that you DO NOT KNOW what awaits under the vocal cords, you can visualize the cords (possibly) and maybe push the tube, but what if there's another tumor/obstruction/foreign body/tracheomalacia several centimeters below the first tumor?

From my point of view there is one very important aspect missing in the discussion:

What ever you do, you have to communicate it with the whole team (ENT surgeon, nurses, etc.)

Incubation with local anesthetic gargles & spray.ultimate way is trachestomy.

In a patient with stridor due to periglottic tumor, it is essential to know with the help of investigations, as suggested earlier, the location -supraglottic or infraglottic. In case of infraglottic tumor with stridor, we go for surgical tracheostomy preoperatively in OT or a day before under LA below the level as suggested by scan . Such cases can be unpredictable as the tumor may have increased in size from the last scan available--so do not try your skills how best you may be at. In patients with supraglottic tumor and that too with stridor, awake airway management is suggested. In such cases, an indirect laryngoscopy if possible would help you give an idea of the glottic area available. Topicalisation and getting an idea of glottic view by gentle pharyngoscopy using videolaryngoscope --CMAC -my preference-if available, can help you give an idea of the tube size and help you intubate the patient. It avoids the risk of obstruction from fibreoptic as suggested. However, in absence of available videolaryngoscopes and lack of patient cooperation with topicalization and laryngoscopy-direct/ indirect; surgical trachesostomy is the best option. The patient is already in stridor and may be hypercapnic: I am sure he will not be much co-operative--in that scenario you cant be testing your skills but you should know to play safe before landing in CVCI. intubation is difficult and any sedation may lead to obstruction or cannot ventilate situation as the patient is already in stridor. My very little experience would somehow still go for surgical tracheostomy as a safe option in stridor patient with periglottic tumor, especially an infraglottic one and probably in supraglottic too as per situation , skills and availabilty of equipment.

Thanks very much Kapil for your helpful comments. I have used videolaryngoscope-assisted awake intubation in 6 cases of peri-glottic tumour successfully (all extrathoracic located above the first tracheal ring but including subglottic tumours). I like your suggestion in using videoscope for evaluating the airway. Nasendoscopy is also very helpful here and is possibly less likely to interfere with breathing of stridulous patient.

I think if you are using the VL with a channel (I used Pentax AWS), then 'cork-in-a-bottle' effect is avoided and if anything the obstruction is eased by you advancing the tube through the obstraction making patients breathing easier in the process.

I completely agree about surgical tracheostomy being safer option when there is lack of skill or equipment availability. We have to remember, however, that awake surgical tracheostomy is often prolonged and difficult procedure, which may be too much to cope for a patient with stridor. This should be taken into account when making a decision about the best method of intubation in this group of patients.

Interesting concept. Have you experienced any problems with kinking of the 2mm cannula during use? Accidental removal of the cannula before surgical airway is secure is also possible risk. This group of patients may not tellerate transtracheal injection as it is presumably more irritable to the airway than nebulised lignocaine or 'sprey-as-you- go' technique of topicalisation.

I presume you are talking about High Freqency Jet Ventilator (or it may be a device that is completely new design). D

I didn't find the presence of the tube in the trachea an issue as most of the surgeons that I work with can work around the airway.

Dr Anthony, we appreciate your technique and may be it is useful. But have you used it in humans also? Also you need specialised computer programming and the may be the equipment may also not be available in every set up. This precludes your technique which may be though useful to be of limited in set up other than yours. If we can find a consensus answer which can be done in every set up , it would be the best. I guess in case of diff in assessment or predicted diff in intubation/ ventilation which you are not skilled to tackle , you should go for surgical tracheostomy. I request all the mmbers to share their experience / views regarding feasibilty and the option of tracheostomy in such a situation

Un my experience, the best option to manage these patients is fiberoptic intubation with local anesthesia and awake patient. In case of emergencie, surgical traqueotomy with local anesthesia would be the election way of airway management.

Thanks very much Anthony for your detailed response to my comments. It seems that many people assumed the set up to be more complex that it actually is. There is (similar in method of use) manual device on the market that allows for active inspiration and expiration but does not have the same level of sofistication and inbuilt safety as your device. It is marketed as VENTRAIN. Does anybody have any experience with this device?

It's depend on patient emergency condition and also your available equipment; In best situation Video Guided Laryngoscopy in awake and blocked stat may appropriate.

The only safe solution is tracheotomia done by Ear Nose Throat Surgeon. If there is no time for this, because of hypoxia or some urgent surgery anywhere else in the body, like bleeding, then it is an interesting question. Going awake with fiber might worsen symptoms due to aditional oedema and bleeding. Video laryngoscope of any kind is better then standard laryngoscopic intubation - I use C-MAC from Storz, perhaps with D-BLADE. But remember that we do not know what awaits us in the trachea - there may be a second tumor there. In dire emergency there is always cricotomy - I was never in my life forced to that :)

Perform a fibreoptic assisted intubation in the awake patient. Using plenty of topical local anaesthetic and with the patient sitting upright intubate the patient on spontaneous ventilation without using any sedatives. This, however, really do require plenty of local anaesthetics. Also - this should not be your first fibreoptic intubation.

Very comprehensive replies from colleagues working within the developed countries. I am sure the replies from the colleagues working in the developing countries or resource-limited settings would also be interesting where there is no FOB or devices which we all know are extremely helpful in achieving certain methods of airway management.

Without access to FOB, my approach would be a two-step approach:

1) Perform an inhalation induction with Sevoflurane. Ensure that the patient has a MAC of at least 2.5 and is way below agitation. Intubate the patient with a conventional laryngoskope (or even a videolaryngoscope) without the use of other drugs. The absence of other drugs provides the anaesthetists with the possibility to simply turn off the gas and wake up the patient while he is still on spontaneous ventilation.

2) Should the patient´s airways prohibit intubation one must use step two: Awake tracheostomy under local anaesthesia.

I politely disagree with Dr. Fabrizio Bonanno: The major factor for decision making is surely the competences of the attending physician. One should not attempt to perform one´s first fibreoptic intubation in a patient like this, nor should one attempt for the first time to intubate a patient on ketamine, remifentanil or, for that matter, sevoflurane.

I find it important that the methods used are methods that can be practised on a daily basis. In my University hospital, we teach the young physicians to perform inhalational inductions followed by intubation in a patient with spontaneous ventilation. It works. The patients accept the inhalation without any problems. Also, it is much safer to have the patient breathing spontaneously without administering opioids. This gives us the security that we have the patient breathing spontaneously with airway reflexes obtunded rather than lively - as would be the case with ketamin.

However: One should practise beforehand. It is too late to embark on an unknown procedure in cases of urgency.

Intubate under local anaesthesia or preoperative tracheostomy

I agree with Fabrizio Bonanno that mentioned ...

Procedure time, patient' situation and timing of intervention are the three preponderant factors for decision making!!! Nothing else.

In proper situation Flexible Fiberoptic Intubation is indicated in distorted airway anatomy; If not available, awake intubation is probably a good alternative. In critical situation surgical airway maybe the best option.

I recently saw the term "SEDATED LOOK" that advised to use Ketamine for moderate sedation along with topical anesthesia (nebulized 4% lidocaine) in selected stable patients, conditions may exist that preclude the immediate use of RSI, and the more prudent approach would be to assess the airway and intubation needs or potential

complications before using paralytics. Examples are patients with angiotensin-converting enzyme inhibitor–induced angioedema or smoke inhalation, where clinical

issues of RSI and intubation can be assessed by directly visualizing the larynx.

(ROBERTS & HEDGES Clinical Procedures in Emergency Medicine (2014), RESPIRATORY PROCEDURES, Page 118)