Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report

Practice and outcomes of airway management in patients with cervical orthoses

BACKGROUND/PURPOSE

Increasing evidence indicates an association of video laryngoscopy with the success rate of airway management in patients with neck immobilization. Nevertheless, clinical practice protocols for tracheal intubation in patients immobilized using various types of cervical orthoses and the outcomes remain unclear.

METHODS

We retrospectively assessed the tracheal intubation techniques selected for patients immobilized using cervical orthoses from 2015 to 2018. The endpoints were the intubation outcomes of the different techniques and the factors associated with the selection of the technique.

RESULTS

We included 218 patients, 118 of whom wore halo vest braces (halo vest group) and 100 wore cervical collars (collar group). GlideScope video laryngoscopy (GVL) and fiberoptic bronchoscopy (FOB) were the initial intubation methods in 98 and 120 patients, respectively. GVL had a higher first-attempt success rate than did FOB in the collar group (p = 0.002) but not in the halo vest group (p = 0.522). GVL was associated with a lower risk of episodes of SaO₂< 90% (adjusted relative risk [aRR], 0.11; 95% CI, 0.02-0.67; p = 0.016) and shorter intubation time (aRR, -3.52; 95% CI, -4.79∼-2.25; p < 0.001) in the collar group. However, in the halo vest group, more frequent requirement of a rescue technique (p = 0.002) and necessity of patient awakening (p = 0.001) was noted when GVL was used. Use of the halo vest brace and noting of severe cord compression were independent predictors of the initial selection of FOB.

CONCLUSION

Caution should be exercised when using GVL for tracheal intubation in patients immobilized using halo vest braces.

Preemptive veno-venous ECMO support in a patient with anticipated difficult airway: A case report

This report presents a case of endotracheal metastasis in which elective veno-venous extracorporeal membrane oxygenation (VV ECMO) was used to undergo tracheal laser-surgery prior to establishment of a definitive airway. Specifically, we describe the respiratory and airway management in an adult patient from the preclinical phase throughout elective preoperative ECMO implantation to postoperative ECMO weaning and decannulation in the Intensive Care Unit. This case report lends further supports to the idea that the extracorporeal membrane oxygenation could be electively used to provide safe environment for surgery in situations where the standard maneuvers of sustaining adequate gas exchange are anticipated to fail.