Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Dec 16, 2022; 10(35): 13088-13098
Published online Dec 16, 2022. doi: 10.12998/wjcc.v10.i35.13088
Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma: A case report and literature review
I-Liang Liu, An-Hsun Chou, Chien-Hung Chiu, Yu-Ting Cheng, Huan-Tang Lin
I-Liang Liu, An-Hsun Chou, Huan-Tang Lin, Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
An-Hsun Chou, Huan-Tang Lin, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
Chien-Hung Chiu, Yu-Ting Cheng, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
Huan-Tang Lin, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
Author contributions: Liu IL provided anesthetic care to the patient, obtained consent for publication, and drafted and revised the manuscript; Chiu CH and Cheng YT provided surgical care to the patient, and reviewed and revised the manuscript for important intellectual content; Chou AH and Lin HT provided anesthetic care to the patient, and reviewed and revised the manuscript accordingly.
Informed consent statement: Written informed consent was obtained from the patient’s wife for the publication of this case report and accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Huan-Tang Lin, MD, Associate Professor, Department of anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5 Fushing 1st Road, Gueishan, Taoyuan 333, Taiwan. sanctuary12@cgmh.org.tw
Received: September 30, 2022
Peer-review started: September 30, 2022
First decision: October 17, 2022
Revised: October 26, 2022
Accepted: November 25, 2022
Article in press: November 25, 2022
Published online: December 16, 2022
Processing time: 74 Days and 23.8 Hours
Abstract
BACKGROUND

Anesthesia for tracheal tumor resection is challenging, particularly in patients with a difficult upper airway. We report a case of a difficult upper airway with a metastatic tracheal tumor causing near-total left bronchial obstruction and requiring emergency tracheostomy and venovenous extracorporeal membrane oxygenation (VV-ECMO) support for rigid bronchoscopy-assisted tumor resection.

CASE SUMMARY

A 41-year-old man with a history of right retromolar melanoma treated by tumor excision and myocutaneous flap reconstruction developed progressive dyspnea on exertion and syncope episodes. Chest computed tomography revealed a 3.0-cm tracheal mass at the carinal level, causing 90% tracheal lumen obstruction. Flexible bronchoscopy revealed a pigmented tracheal mass at the carinal level causing critical carinal obstruction. Because of aggravated symptoms, emergency rigid bronchoscopy for tumor resection and tracheal stenting were planned with standby VV-ECMO. Due to limited mouth opening, tracheostomy was necessary for rigid bronchoscopy access. While transferring the patient to the operating table, sudden desaturation occurred and awake fiberoptic nasotracheal intubation was performed for ventilation support. Femoral and internal jugular vein were catheterized to facilitate possible VV-ECMO deployment. During tracheostomy, progressive desaturation developed and VV-ECMO was instituted immediately. After tumor resection and tracheal stenting, VV-ECMO was weaned smoothly, and the patient was sent for intensive postoperative care. Two days later, he was transferred to the ward for palliative immunotherapy and subsequently discharged uneventfully.

CONCLUSION

In a difficult airway patient with severe airway obstruction, emergency tracheostomy for rigid bronchoscopy access and standby VV-ECMO can be life-saving, and ECMO can be weaned smoothly after tumor excision. During anesthesia for patients with tracheal tumors causing critical airway obstruction, spontaneous ventilation should be maintained at least initially, and ECMO deployment should be prepared for high-risk patients, such as those with obstructive symptoms, obstructed tracheal lumen > 50%, or distal trachea location.

Keywords: Tracheostomy; Extracorporeal membrane oxygenation; Tracheal tumor; Melanoma; Case report

Core Tip: Perioperative management of obstructive tracheal masses is challenging for anesthesiologists. The patient’s history should be combined with thoroughly preoperative examinations to establish meticulous anesthesia plans and prepare for alternatives in case of emergency. Here, we report a rare case of tracheal melanoma concomitant with a difficult upper airway. We also review the case management of tracheal melanomas in the literature. No global consensus exists on the indications and timing of extracorporeal membrane oxygenation (ECMO) use in patients with tracheal masses. Spontaneous ventilation should be maintained until the airway is definitely secured, and preparing for the availability of ECMO is also suggested.