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The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review

  • Gemma Malpas
  • Orlando Hung
  • Ainslie Gilchrist
  • Chrison Wong
  • Blaine Kent
  • Gregory M. Hirsch
  • Robert D. Hart
Review Article/Brief Review

Abstract

While extracorporeal membrane oxygenation (ECMO) is an effective method of oxygenation for patients with respiratory failure, further refinement of its incorporation into airway guidelines is needed. We present a case of severe glottic stenosis from advanced thyroid carcinoma in which gas exchange was facilitated by veno-arterial ECMO prior to achieving a definitive airway. We also conducted a systematic review of the MEDLINE, EMBASE, CINAHL, and Web of Science databases, using the keywords “airway/ tracheal obstruction”, “anesthesia”, “extracorporeal”, and “cardiopulmonary bypass” to identify reports where ECMO was initiated as the a priori method of oxygenation during difficult airway management.Thirty-six papers were retrieved discussing the use of ECMO or cardiopulmonary bypass (CPB) for the management of critical airway obstruction. Forty-five patients underwent pre-induction of anesthesia institution of CPB or ECMO for airway obstruction. The patients presenting with critical airway obstruction had a range of airway pathologies with tracheal tumours (31%), tracheal stenosis (20%), and head and neck cancers (20%) being the most common. All cases reported a favourable patient outcome with all patients surviving to hospital discharge without significant complications.While most practitioners are familiar with the fundamental airway techniques of bag-mask ventilation, supraglottic airway use, tracheal intubation, and front-of-neck airway access for oxygenation, these techniques have limitations in managing patients with pre-existing severe airway obstruction. The use of ECMO should be considered in patients with severe (or near-complete) airway obstruction secondary to anterior neck or tracheal disease. This approach can provide essential tissue oxygenation while attempts to secure a definitive airway are carried out in a controlled environment.

Recours à l’oxygénation extracorporelle en prévision de la gestion de voies respiratoires difficiles : rapport de cas et étude systématique

Résumé

L’oxygénation par membrane extracorporelle (ECMO) est une méthode d’oxygénation efficace chez les patients présentant une insuffisance respiratoire, mais il est nécessaire de mieux préciser son inclusion dans les lignes directrices concernant la gestion des voies respiratoires. Nous présentons un cas de sténose sévère de la glotte due à un carcinome de la thyroïde dans lequel l’échange gazeux était facilité par une ECMO veino-artérielle avant la réalisation d’un accès des voies respiratoires définitif. Nous avons aussi effectué une revue systématique des bases de données MEDLINE, EMBASE, CINAHL et Web of Science en utilisant les mots clés « obstruction des voies respiratoires/de la trachée », « anesthésie », « extracorporelle » et « circulation extracorporelle » pour identifier des cas dans lesquels une ECMO a été mise en place comme méthode d’oxygénation a priori au cours de la gestion de voies respiratoires difficiles. Trente-six articles discutant de l’utilisation de l’oxygénation ou de la circulation extracorporelle dans la gestion des obstructions majeures des voies respiratoires ont été retenus. Quarante-cinq patients ont subi une préinduction d’anesthésie par oxygénation ou circulation extracorporelle en raison d’une obstruction des voies respiratoires. Les patients présentant une obstruction majeure des voies respiratoires étaient principalement des patients atteints de tumeurs de la trachée (31 %), sténose de la trachée (20 %) et de cancers de la tête et du cou (20 %). Dans tous les cas, l’évolution des patients a été favorable : ils ont pu quitter l’hôpital en vie et sans complications significatives. Bien que la majorité des praticiens connaissent les techniques de base de ventilation au masque et au ballon, l’utilisation des voies respiratoires supraglottiques et l’accès cervical antérieur des voies respiratoires pour assurer une oxygénation correcte, ces techniques ont des limites dans la gestion de patients ayant une obstruction préexistante sévère des voies respiratoires. L’utilisation de l’oxygénation extracorporelle devrait être envisagée chez les patients ayant une obstruction sévère (ou quasi complète) des voies respiratoires à la suite d’une maladie de la trachée ou du segment antérieur du cou. Cette approche peut procurer une oxygénation tissulaire essentielle pendant que des tentatives visant à assurer un accès définitif des voies respiratoires sont menées dans un environnement contrôlé.

Notes

Conflicts of interest

The authors declare no competing interests.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Gemma Malpas contributed to the study design, literature search, interpretation of data, manuscript preparation, and validation of contents. Orlando Hung contributed to the study design, interpretation of data, manuscript preparation, and validation of contents. Ainslie Gilchrist contributed to the case report and manuscript preparation. Chrison Wong contributed to the case report, literature search, and manuscript preparation. Blaine Kent, Greg Hirsch, and Robert D. Hart contributed to the manuscript preparation.

Funding

Support was provided solely from institutional and/or departmental sources.

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Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Gemma Malpas
    • 1
  • Orlando Hung
    • 1
  • Ainslie Gilchrist
    • 1
  • Chrison Wong
    • 1
  • Blaine Kent
    • 1
  • Gregory M. Hirsch
    • 3
  • Robert D. Hart
    • 2
  1. 1.Department of Anesthesia, Pain Management and Perioperative Medicine, Queen Elizabeth II Health SciencesDalhousie UniversityHalifaxCanada
  2. 2.Division of Otolaryngology-Head and Neck Surgery, Department of SurgeryDalhousie UniversityHalifaxCanada
  3. 3.Division of Cardiac surgery, Department of SurgeryDalhousie UniversityHalifaxCanada

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