Clinical Case 143: a Perfect Airway Storm

This episode I reflect upon a really tough airway case.

I have asked a number of airway gurus from the FOAMed community to comment on the logistics and plan to manage this case.  Thanks to Tim Leeuwenburg, Rich Levitan, Roger Harris and Dr Richard Lewis of their contributions.

The patient

50 year old woman with a complicated medical history.

  • life long smoker & drinker
  • had large goitre resected 10 years ago with large anterior neck dissection
  • diagnosed with SCC of base tongue 3 years ago
  • large resection / reconstruction including mandibular graft
  • Radiation therapy to the anterior neck with lots of fixed scarring to neck.
  • Previous intubation (prior to XRT) was grade 3 and required a bougie for anterior larynx / hyper-angulated airway
  • Now quite cachexic but has no palliative intention

The situation

Presents to a remote ED (2000km from the next specialist ENT / Anaesthesia /ICU service.

Developed oral bleeding from fungating lesion on the posterior lateral tongue.

Has been contiuously bleeding for an hour, tachy 130, normal BP, has a bag of blood in hand ~ 1000 ml.

Vomited a few times – altered blood / coffee grounds

On examination there is a fungating lesion that we cannot see past ie. You can see the front of the lesion covered in an oozing clot but it extends past the possible field of view around the back of the tongue.

The jaw is microagnathic / graft with a lot of scar tissue.

The anterior larynx is best described as a block of fixed tissue with woody texture. It is impossible to clinically feel the cricothyroid / thyroid cartilage or membrane reliably


Bloods – Hb is now 79 (was 110 on recent check). Platelets 150

Normal renal function

Coags are normal

LFTs – raised GGT and ALT – chronic

No imaging / CT available

The problem

This patient is exsanguinating – we need to control the bleeding. IV TXA, topical adrenaline and TXA gauze help control external bleeding, but she still seems to be gagging and swallowing a lot of blood, vomiting intermittently coffee grounds.

We have blood to transfuse ready to go…

To do this properly we need to control the airway / get a tube in place.

How should we do this…?

AFOI – is going to be tricky

RSI – also requires we accept the risk of going to surgical airway…. Which may be tricky

Needs to go to the tertiary hospital on a plane… this is unlikely to occur without a secured airway.

OK doc – the surgeon is scrubbed and ready to get in there… what the plan?

What do you do if AFOI proves to be impossible / failed?

Have a listen to hear how it played out and what the airway experts think!



  1. From reader , Dr H

    Liked the airway case. My worst airway was a 54y man who walked past me in busy ed (single doctor 6 beds, 5 full, waiting room full of people waiting to be seen). Looked well, but had stridor. I went to see him while the nurse was triaging him, he was talking and joking, just wanted AB for a cough that was getting worse. Did urgent CXR- Got called to Xray to see the result- huge chest mass. We have a CT so did that- only lying him flat at the last minute for the CT. CT showed a huge mass in the upper chest,. Patient got very SOB lying flat and more stridor, so sat back up, in ED started having severe trouble breathing. As stridor – > neb adrenaline, non stop. CT showed his trachea was narrowed to 4 mm , down behind the sternum. So surgical airway wasnt going to work.!. Long story short- I took him by road to meet retreval in a roadside carpark. Made it to tertiary hospital and they did awake intubation. Mass was a goitre, that had bleed into a cyst , probably from his coughing. V Scary.

    Thank you for sharing

    • Adnane Lahlou says

      Gave me the chills there. I belive trying to secure the airway with a small caliber tube wouldn’t have worked either.

  2. Jim DuCanto says

    MY KIND OF CASE–THANK YOU! Finally getting to this today.
    My thoughts:
    –While listening to the case (before you revealed what you did:
    1a. Fix the hemodynamics, anemia, anxiety, oxygenation first (as you did)
    1. Retrograde technique via 18 gauge angiocath placed with the Ultrasound. It can be done as classically described, or it can retrograde feed through suction/working channel of bronchoscope.
    2. Nasal approach as you did, can be done blind if necessary (with spontaneous ventilation
    –As you were in operating room determining that you can face mask ventilate
    1.The supraglottic airway approach becomes viable for sure
    –As you were fiber optically intubating
    1. You could see the larynx, but you just couldn’t get there. Your endoscope may have been too small/wimpy to make the bend (even on a nasal vector). Oh well. Sometimes something as simple as a jaw thrust (bimanual by an assistant) can help that.
    2. A gentle lift of the tongue from the base (tongue depressor, possibly with the D-Blade) may have brought you into alignment. A colleague without fear can do this with gloved digits. Just as a caveat–adults will bite you and then let go, kids will bite–and hold on!
    3. Something for Tim Leeweunberg and I to investigate in simulation is to use a wire THROUGH the suction/instrument channel of the bronchoscope to in effect work as a bougie-intubating catheter FOR THE BRONCHOSCOPE. It will NEVER WORK unless you have tried it first in simulation (cool, another thing to try in the labor me and Tim).
    4. You were smart to stop and regroup.
    5. You were wise and compassionate to monitor the patient. If your hand was forced, you’d go into that airway with all your tech up front–Hypecurved VL, Suction, Highflow NC AND the bronchoscope loaded up with a tube.
    6. You have blessed us with the holiday perfect storm case. Thank you!!!

  3. Keith Greenland says

    Hi Casey

    Firstly well done. The “anticlimax” you referred to sounds like the perfect result for both patient and staff.

    Some thoughts:
    1. I spent time in both tertiary and remote hospitals. Surgeons in remote areas have an under-appreciated skill-base. They are often very modest but fantastic to work with in extremely difficult situations. They don’t mind a drink after it’s all over!
    2. A gentle nasopharyngoscopy is possible my first step if bleeding is not torrential. First, clear airway as much as possible with a wide-bore soft “Y” suction catheter. The suction channel in a fibreoptic scope barely copes with minor amounts of saliva and performs badly with blood/clots. Have a look and get more info about the size of the lesion and likely airway passage(s). If you can get scope through the cords, fantastic. If not, nothing lost but you’ve gained some valuable info above lesion size and shape. Not likely to create more bleeding if gentle – keep tip of scope in middle of airway and gentle insertion. Centre-move-centre.
    3. The fact you couldn’t get through the vocal cords with FOB happened to me about 7 years ago (once is almost 30 years as anaesthetist). My patient was morbidly obese patient with a massive multinodular goitre for elective (actually colleagues case but I was asked to help after he failed with awake FOB). The anatomy was severely distorted. After many attempts by 2 anaesthetists the surgeon performed awake trache – incision was lateral neck because the glottis was pushed severely to the left and rotated almost 90 degrees. Reason for failed FOB? I think this occurs because the only significant manoeuvring occurs in the distal 3cms of scope. The rest of the scope lies along the airway and contacts it at a few key points. One of these is the apex of the primary curve or posterior 1/3 of tongue. The ability to insert the tip of the FOB through the cords requires some compliance of the submandibular tissues. In your case and mine, I don’t believe the compliance was there and the FOB tip is like a “dog on a leash trying to get a bone”. No matter how you manipulate the scope, it can’t reach the cords because the scope is “tethered” by the apex. One theoretical solution is to do a retromolar approach with the scope (similar to straight laryngoscope blade) to bypass the tongue base. Fortunately this problem is rare but an analysis of the airway configuration is key to understanding the problem and improves your skill base.
    4. Awake trache is a reasonable solution but may I suggest some nuances I have found works for me in similar circumstances. Surgeon performs trache in semi-reclined position. Patient will feel better than supine and be more co-operative. Lots of local anaesthesia, holding patient’s hand and reassurance. Patient should not talk as the anatomy moves. When trachea is about to be opened, expect lots of coughing and blood splatter. Don’t panic and let patient settle before proceeding. Insert small tracheal tube rather the trache tube. Latter has a stylet and patient unable to breath while the stylet is in place. The small tube can be replaced later when the patient’s airway is controlled and anaesthetised/paralysed. If the surgeon has a poor view of the tracheotomy, get he/her to insert bougie first. This will make the patient cough again and surgeon needs to hold it firmly in place during the coughing fit. A bougie is a foreign device to the surgeon so a quick rundown on how it is used is key to making the next few steps as quick and efficient as possible for the patient’s sake.
    5. Agree that trache has long-term issues. My understanding is patient may struggle to be decanulated later unless the lesion is debulked. While it is important to secure the airway, patient wellbeing from point of contact through to their death is important considerations. Interesting to hear more from ENT/Head and Neck surgeons on this issue.
    6. LMA + FOB and Aintree catheter is a viable option in the management algorithm. Once seated, the cuff protects the vocal cords and FOB from further blood contamination. You amy scoop up some blood in the LMA bowl during insertion but stay above this when inserting FOB. Usually use an LMA one size down for these retrognathic patients with bone grafts and post-radiotherapy. Remember No3 LMA is too small for FOB + Aintree catheter so only No4 and No 5 can be used.
    7. Reason for the bleeding to stop? Was the patient sedated during the FOB attempts? If so, it’s possible the BP/PR settled and the drugs started to work.

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