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.

Table 2 Case management of primary and metastatic tracheal melanoma in the literature

Ref.	Year	Age	Sex	Primary/metastatic	Original site	Symptoms	Obstructiona	location	Size	Management	IHC Stain	Outcome
Rosenberg et al[5]	1965	46	F	Metastatic	cheek	Hemoptysis	Grade III stenosis	Carina	3.5 cm	Partial excision	-	Died 9.5 yrs later
Mori et al[6]	1977	47	F	Primary	tracheal	Dyspnea	Grade I stenosis	Mid-trachea	1.5 cm	Resection and anastomosis	--	Alive 1 yr later
Andrews et al[7]	1981	28	M	Metastatic	shoulder	Dyspnea, hemoptysis	50% obstruction	distal trachea	---	laser	-	Died 10 days later
Castro et al[8]	1990	68	M	Metastatic	nasal	Dyspnea	90% obstruction	Carina	Large	YAG laser	-	No recurrence in 9 months
Duarte et al[9]	1998	32	F	Primary	tracheal	Exertional dyspnea	85% obstruction	6cm below vocal cord	2.3 cm × 1.3 cm	Resection and anastomosis	HMB-45(+), S100(+)	Died 13 months later
Koyi et al[10]	2000	54	M	Metastatic	shoulder	Dyspnea	50% obstruction	Carina	--	YAG laser	--	Died 4 months later
Capaccio et al[11]	2002	61	F	Metastatic	shoulder	Dyspnea	Grade III stenosis	Mid-trachea	1.5 cm × 1 cm	Tracheostomy, Argon plasma coagulation	-	Died 3 months later
Bardia et al[12]	2006	42	F	Metastatic	foot	Dyspnea	50% obstruction	Subglottic	---	Tracheostomy and radiotherapy	--	Alive 1 yr later
Terra et al[13]	2008	29	F	Primary	tracheal	Dyspnea	90% obstruction	3 cm below vocal cord	2.5 cm × 1.7 cm × 0.5 cm	Tracheostomy, resection and anastomosis	HMB-45(+), S100(+)	Survived 4 yrs after diagnosis
Cekin et al[14]	2010	22	M	Primary	tracheal	Dyspnea and hoarseness	80% obstruction	Mid-trachea	1.5 cm × 2 cm	Tracheotomy, resection and anastomosis	HMB-45(+), Melan-A(+), S100(+)	Alive 3 yrs later
Nureki et al[15]	2012	73	M	Primary	Tracheal	No symptoms	Grade I stenosis	Mid-trachea	9 mm	Resection and anastomosis		Died 2 yrs later
Shelton et al[16]	2013	58	M	Metastatic	arm	Hemoptysis	Grade I stenosis	Mid-trachea	-	laser	-	Not mentioned
Heyman et al[17]	2013	64	M	Metastatic	anorectal	Cough	75% obstruction	Distal trachea	-	Argon plasma coagulation	-	Died 9 days later
Mark et al[18]	2013	64	M	Primary	laryngotracheal	Exertional dyspnea	Grade III stenosis	Subglottic	1.3 cm × 4.9 cm	Awake tracheostomy, tumor resection	Pan melanin (+), S100(-)	Hospice care 10 months later
Imai et al[19]	2015	68	M	Primary	Tracheal	Stridor, hemoptysis	90% obstruction	Carina	2.5 cm × 2 cm × 1.5 cm	Chemotherapy, radiotherapy	HMB-45(+), Melan-A(+), S100(+)	Not mentioned
Purcell et al[20]	2015	50	F	Metastatic	Shoulder	Stridor, dyspnea	90% obstruction	Mid-trachea	-	Bronchoscopic resection	-	Alive 6 months later
Costa et al[21]	2017	85	F	Thyroid metastasis	Nasal	Dyspnea	> 50% obstruction	Mid-trachea	-	Thyroidectomy	HMB-45(+),S100(+)	Died 5 months later
Fung et al[22]	2018	73	F	Tracheal metastasis	Nasal	Dyspnea at rest	Nearly-total obstruction	Distal trachea	-	Preemptive VV-ECMO, tumor resection	--	Died 4 months later
Trugillo et al[23]	2019	47	M	Metastatic	Nasal	Dyspnea	90% obstruction	Mid-trachea	-	resection	-	Not mentioned
Siraneci et al[24]	2020	80	F	Thyroid metastasis	Unknown	Dyspnea, stridor	Grade III stenosis	1cm below vocal cord	---	Metal stent	HMB-45(-), S100(+)	Died 2 wks later
Cruz et al[25]	2020	45	M	Primary	Tracheal	Cough, hemoptysis	< 20% obstruction	Cricoid level	Small	Argon plasma coagulation	-	Immunotherapy, alive 2 yrs later
Present case	2022	41	M	Metastatic	Retromolar	Exertional dyspnea, hemoptysis, syncope	90% obstruction	carina	3 cm x 2.5 cm x 2 cm	Rescue VV-ECMO, tumor resection, tracheal stent	HMB-45(+), Melan-A(+), S100(+)	Died 1 yr later

ECMO: Extracorporeal membrane oxygenation; VV: Veno-venous; IHC stain: Immunohistochemistry stain.

^aObstruction is defined as the percentage of obstructed tracheal lumen or grade of subglottic stenosis according to the Meyer-Cotton grading scale. Grade 1 stenosis is defined as a lumen obstruction of < 50%. Grade 2 stenosis is 51%-70% of lumen obstruction. Grade 3 stenosis accounts for 71%-99% of lumen obstruction.