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

Table 1 Comparison between serial anesthesia management for this patient with different degree of tracheal obstruction

Time point		Surgery	Previous symptoms	Airway	Induction anesthetics	Airway management	Muscle relaxation	Oxygen support	PaO2 (mmHg)a	PaCO2 (mmHg)a	Subsequent management	Outcome
October 8, 2019 (age 40 yr)		Right temporal craniotomy	No respiratory distress	20% obstruction at carinal level	Fentanyl, propofol	Awake nasal fiberoptic intubation	Yes (after intubation)	1 L/min, FiO2 100%	461	28.8	Extubation at OR	Uneventful
February 19, 2020 (age 41 yr)		Oral commissure reposition	No respiratory distress	50% obstruction at carinal level	Fentanyl, propofol	Awake nasal fiberoptic intubation	Yes (after intubation)	1 L/min, FiO2 70%	368	32	Extubation at OR	Uneventful
May 23, 2020 (age 41 yr)	At OR, before induction		Smooth respiration in supine position	90% obstruction at carinal level		Spontaneous respiration under O2 mask	No	O2 mask 10 L/min	63.7	42.3	Oxygen support, set monitoring	Prepare for tracheal tumor excision
	After intubation	Tracheostomy, rigid bronchoscopy-assisted tracheal tumor excision, and tracheal stent insertion	Sudden desaturation after transferring to OR bed	90% obstruction at carinal level	Fentanyl, propofol	Awake nasal fiberoptic intubation, spontaneous respiration via ETT	No	2 L/min, FiO2 100%	58.2	46.6	Intermittent positive pressure ventilation; prepare VV ECMO access	Progressive desaturation
	During tracheostomy, before VV ECMO		Desaturation due to cough, tumor bleeding, or airway compression	90% obstruction at carinal level	Propofol	Spontaneous respiration via ETT	No	2 L/min, FiO2 100%	48.9	45.4	Intermittent positive pressure ventilation, prepare ECMO deployment	Decompensation
	After VV ECMO deployment		Desaturation during tracheostomy	90% obstruction at carinal level	Propofol, cisatracurium	Tracheostomy, mechanical ventilation	Yes (after ECMO deployment)	2 L/min, FiO2 100%	84.2	27.1	Rigid bronchoscopy-assisted tracheal tumor excision, and tracheal stent insertion	Improved oxygenation
	After tracheal tumor excision		Improved oxygenation under ECMO support	Tracheal stent	Propofol, cisatracurium	Tracheostomy, mechanical ventilation	Yes	1 L/min, FiO2 100%	220.3	41.3	ECMO weaned	ICU care
	After ECMO removal		Improved oxygenation after tumor removal	Tracheal stent	Propofol, cisatracurium	Tracheostomy, mechanical ventilation	Yes	1 L/min, FiO2 80%	260.3	39.4	ICU care	Uneventful

ECMO: Extracorporeal membrane oxygenation; OR: Operating room; ICU: Intensive care unit; ETT: Endotracheal tube;

^aPaO₂ and PaCO₂ values were obtained from perioperative arterial blood gas analysis.